Friday, August 31, 2012

Q: What is "Whoosh test"? 

Answer: The whoosh test is done by rapidly injecting air down the NasoGastric tube while auscultating over the epigastrium. Gurgling indicates probability of NGT in the stomach, whilst its absence suggests NGT is elsewhere (lung, oesophagus, pharynx etc).

Wednesday, August 29, 2012

Q: Which patients are at high risk of protamine reaction?

  • Diabetics on NPH insulin,
  • patients allergic to fish,
  •   pregnant and nursing women,
  • previous protamine exposure, and
  • men who have had vasectomies.

Monday, August 27, 2012

Q: Ischemic colitis remained a clinical diagnosis. Despite normal labs or no bloody stools, which one clinical sign should promptly lead to diagnosis of Ischemic colitis?
Answer: "pain out of proportion to physical findings", specifically excruciating abdominal pain despite limited focal tenderness. Labs and other clinical signs may lag behind.
Q: Describe at least 5 clinical signs at bedside for diagnosis of acute appendictis?

Answer:  Various clinical maneuvers have been described to diagnose acute appendicitis. Some of the tests to perform are mentioned  below.

1. Rovsing's sign: Continuous deep palpation starting from the left iliac fossa upwards (counterclockwise along the colon) may cause pain in the right iliac fossa

2. Psoas sign or Obraztsova's sign:  is right lower-quadrant pain that is produced with either the passive extension of the patient's right hip (patient lying on left side, with knee in flexion) or by the patient's active flexion of the right hip while supine. The pain elicited is due to inflammation of the peritoneum.

3. Dunphy's sign: Increased pain in the right lower quadrant with coughing.

4. Sitkovskiy or Rosenstein's sign: Increased pain in the right iliac region as patient lies on his/her left side.

5. Rebound tenderness: Deep palpation of the viscera over the suspected inflamed appendix followed by sudden release of the pressure causes the severe pain on the site (Blumberg's sign).  

Sunday, August 26, 2012

Q: ID service advise you to consider Octreotide for a patient with Aids related diarrhea. What is the dosing?

Answer: 100 to 500 mcg SC tid

Though evidence is weak but Octrotide has been used in AIDS related refractory chronic diarrhea. Octreotide is a candidate drug for the treatment of these patients as it inhibits gastrointestinal motility and increase the transit time.

Friday, August 24, 2012

Q: 58 year old male with Renal failure, but not yet on dialysis, is admitted with ST elevation MI and taken to cath lab for PCI and stent placement. Patient is back in unit and has been written to be started on glycoprotein IIb/IIIa inhibitor. What would be your choice?

Answer: Reopro Eptifibatide gets renal elimination and in such patients Abciximab (Reopro) would be a better choice.

In case Integrilin has to be given, renal dosing should be provided.

Thursday, August 23, 2012

Update on platelet inhibition assay (for Plavix monitoring) 

 The VerifyNow P2Y12 assay is used for monitoring platelet inhibition for patients on medications like clopidogrel (plavix). The company has modified the assay so that, from now on, the instrument will only report out in “P2Y12 Reaction Units” or PRU, % inhibition will no longer be reported. 

The normal reference range is 194-418 PRU. Based on a review of the literature, the optimal P2Y12 result for patients on clopidrogrel is approximately 240 – 180 PRU. 

  •  above 240 PRU the patient is at increased risk of thrombosis, 
  •  below 180 PRU the patient is at increased risk of bleeding.

Wednesday, August 22, 2012

Q: While working in ICU you over heard on hospital paging system "Code Silver". What does it mean?

Answer: A person with weapon in hospital!

Hospitals may use their own codes but few codes are universally and informally shared by all.

Tuesday, August 21, 2012

Sunday, August 19, 2012

Q: During clinical exam for adrenal insufficiency, which 2 sites should be look for 'tanning'?

Answer: Addison's disease (adrenal insufficiency) may present with tanning of the skin that may be patchy or even all over the body. 2 characteristic sites of tanning to look for are skin creases (as of the hands) and the inside of the cheek (buccal mucosa).

Monday, August 13, 2012

Q: Why steroids remain mainstay of treatment in Neurocysticercosis?

Answer: Albendazole and Praziquantel are both effective in treatment of Neurocysticercosis. They are given under cover of steroids. Steroids are essentially needed as inflammatory reactions to the dying parasite could be life threatening with mental status changes and convulsions.

Also, Albendazole when co administered with a steroid (to treat inflammation) results in increased absorption of albendazole.

Both Albendazole and Praziquantel are recommended to give with fatty meal.

Sunday, August 12, 2012

Earplugs in ICU

"The use of earplugs during the night lowered the incidence of confusion in the studied intensive care patients. A vast improvement was shown by a Hazard Ratio of 0.47 (95% confidence interval (CI) 0.27 to 0.82). Also, patients sleeping with earplugs developed confusion later than the patients sleeping without earplugs. After the first night in the ICU, patients sleeping with earplugs reported a better sleep perception."

Read interesting article recently published at

Saturday, August 11, 2012

Q: Inverted sleep-wake pattern (i.e sleeping by day and being awake at night), is the hallmark or at least sign of which encephelopathy?

Answer: Hepatic Encephelopathy

Mild to moderate hepatic encephalopathy is characterized by forgetfulness, confusion, irritability, inverted sleep-wake pattern, irritability, tremors etc.

Friday, August 10, 2012

Q: 52 year old male patient has been overdosed in ICU with Ambien (Zolpidem) due to medication error. What intervention may help to diagnose as well as reverse the effect of Ambien?

Answer: Flumazenil

Zolpidem's (ambien) hypnotic effects are similar to those of the benzodiazepine, though molecularly it is distinct from the classical benzodiazepine. But due to similarlity in their hypnotic effects, Flumazenil which is a benzodiazepine receptor antagonist, also reverses zolpidem's sedative/hypnotic effect.

Thursday, August 9, 2012

Q: Which drug overdose may present as ST elevation MI?

Answer: Eszopiclone (lunesta)

Lunesta is unique in a sense that its overdose may presents as ST elevation MI with increase Troponin due to coronary vasospasm. It may lead to V. Fib. as well as cardiac arrest.

Lunesta overdose: ST-elevation coronary vasospasm, troponemia, and ventricular fibrillation arrest.- Am J Emerg Med. 2006 Oct;24(6):741-6.

Wednesday, August 8, 2012

Q: Which ACE Inhibitor is well known to cause taste disturbances?

Answer: Captopril

Taste disturbance, infrequent with most ACE inhibitors, is more prevalent in captopril and is attributed to its sulfhydryl moiety. Though captopril is not in much use in USA, it is still very much in use in developing countries due to its cost effectiveness.

Tuesday, August 7, 2012

Q: In Ascites, if patient requires both spironolactone and furosemide - what combination minimize the danger of hypokalemia?

Answer: Generally, patients with ascites respond well to spironolactone. For nonresponders, a loop diuretic may also be added.

The ratio of 100 mg : 40 mg reduces risks of hypokalemia.

Monday, August 6, 2012

Q: 23 year old male is admitted to ICU after severe Abdominal pain. CT scan reports foreign body obstruction. GI service performed upper and lower GI scope and advised surgical consult. Their diagnosis was Rapunzel syndrome?

Answer: The Rapunzel syndrome is a rare intestinal condition resulting from condition called trichophagia (eating hair).

Trichophagia is a severe form of condition called Trichotillomania (also known as "trichotillosis"). It is the compulsive urge to pull out one's own hair leading to noticeable hair loss. In trichophagia, people with trichotillomania may also ingest the hair that they pull; which can lead to a hair ball formation in GI tract called trichobezoar, and may cause GI obstruction.

Rapunzel syndrome, is an extreme form of trichobezoar in which the "tail" of the hair ball extends into the intestines, can be fatal if misdiagnosed. Because the human gastrointestinal tract is unable to digest human hair, the trichobezoar may require surgical treatment.

The syndrome is named after the long-haired girl Rapunzel in the fairy tale.

Sunday, August 5, 2012


Q: What is Ribot's law of retrograde amnesia?

Answer: Ribot's Law of retrograde amnesia states that there is a time gradient in retrograde amnesia, so that recent memories are more likely to be lost than the more remote memories.

Some examples are, in which bilingual patients recovered different languages with differential progress. In some cases, aphasics recover or preferentially improve only the first-acquired language.

Please note, in Neurology, Ribot’s Law is not universally accepted.

Saturday, August 4, 2012

Q: Central pontine myelinolysis (CPM) is well known to occur due to rapid correction of sodium in hyponatremia. What other conditions may cause CPM?

Answer: It is true that most common cause of Central pontine myelinolysis (CPM) is too rapid correction of low sodium in hyponatremia. Second most common cause is withdrawal of chronic alcoholism.

Other conditions described to cause CPM includes following hematopoietic stem cell transplantation, severe liver disease, following liver transplant, severe burns, malnutrition and hyperemesis gravidarum.

Friday, August 3, 2012

Q: What are the 3 major causes of false or factitious or pseudo hyponatremia?


1. Severe hypertriglyceridemia,
2. Massive elevation of immunoglobulins as in multiple myeloma,
3. Severe hyperglycemia.

Thursday, August 2, 2012

Q: Kernig's sign and Brudzinski's sign are well known in Meningitits. What is Jolt test or "jolt accentuation maneuver" to rule out meningitis?

Answer: The "jolt accentuation maneuver" helps to rule out meningitis in patients with fever and headache. The patient is told to rapidly rotate head horizontally; if this does not make the headache worse, meningitis is unlikely.

Wednesday, August 1, 2012

Q: Is Verapmil an anti- malarial drug?

Answer: Sort of !!

Verapamil has shown potential use in the treatment of malaria as an adjuvant treament with chloroquine particularly in resistance. Resistance to chloroquine is caused by the parasite cell's ability to expel the drug outside of its digestive vacuole. Verapamil, when used in combination with chloroquine, enhances the accumulation of chloroquine within a parasitic cell's digestive vacuole, rendering it incapable of detoxifying itself and making it more susceptible to death.

Recent resistance to the anti-malarial drug chloroquine has hindered the treatment of malaria in Southeast Asia, South America and Africa. Adjuvant use of verapamil may be useful in such circumstances.

Martin, S.; Oduola, A.; Milhous, W. (1987). "Reversal of chloroquine resistance in Plasmodium falciparum by verapamil". Science 235 (4791): 899–901